Nursing Elites

1. A nurse is admitting a client who is in labor and at 38 weeks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2 (HSV-2). Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this scenario is whether they have any active lesions. Active lesions from HSV-2 during labor increase the risk of neonatal transmission, which would necessitate a cesarean section to prevent the infant from contracting the virus during delivery. Asking about the presence of active lesions is crucial to determine the appropriate management and precautions needed to protect the newborn. Choices A, B, and D are not as pertinent in this situation and do not directly address the potential risk of neonatal transmission of HSV-2.

2. A nurse is caring for a client who is postoperative following a thyroidectomy. The client reports tingling in the fingers and around the mouth. The nurse should anticipate which of the following interventions?

• A. Administer calcium gluconate
• B. Provide a high-protein diet
• C. Administer levothyroxine
• D. Apply a warm compress to the client's neck

Correct answer: A

Rationale: Tingling in the fingers and around the mouth is a sign of hypocalcemia, which can occur after thyroid surgery due to accidental damage to the parathyroid glands. Hypocalcemia is common after thyroidectomy due to potential parathyroid damage. Calcium gluconate is the appropriate intervention to treat hypocalcemia. Providing a high-protein diet or administering levothyroxine are not indicated for hypocalcemia. Applying a warm compress to the client's neck would not address the underlying issue of hypocalcemia.

3. A healthcare provider is educating a patient on the use of alendronate. Which of the following should be included?

• A. Take it with food
• B. Take it once a week
• C. It can be taken at bedtime
• D. Monitor for increased appetite

Correct answer: B

Rationale: The correct answer is B: 'Take it once a week.' Alendronate is typically taken once a week to treat osteoporosis. It should be taken on an empty stomach in the morning with a full glass of water. Choice A is incorrect because alendronate should be taken on an empty stomach, not with food. Choice C is incorrect because alendronate should be taken in the morning, not at bedtime. Choice D is unrelated to alendronate use and not a common side effect associated with this medication.

4. A client is receiving vancomycin. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Serum creatinine
• C. INR levels
• D. Liver function tests

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.

5. A nurse is caring for a client with a sealed radiation implant. Which action should the nurse take?

• A. Remove dirty linens after double-bagging
• B. Wear a dosimeter badge
• C. Limit visitors to 1 hour per day
• D. Ensure family remains 3 feet away from the client

Correct answer: B

Rationale: The correct answer is B: Wear a dosimeter badge. When caring for a client with a sealed radiation implant, the nurse should wear a dosimeter badge to monitor radiation exposure. This badge helps measure the amount of radiation the nurse is exposed to during care. Choice A is incorrect because removing dirty linens after double-bagging is not directly related to managing radiation exposure. Choice C is incorrect as there is no specific time limit on visitors mentioned in the context of a sealed radiation implant. Choice D is incorrect as there is no evidence supporting the need for family members to stay a specific distance away from the client.

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